# Indocyanine green-assisted lymphography for intraoperative chyle leak prevention during esophageal cancer surgery: a systematic review of the literature

## TL;DR

This review shows that using indocyanine green-assisted lymphography during esophageal cancer surgery helps prevent chyle leaks and improves lymph node harvesting.

## Contribution

The study systematically evaluates ICG-Lg's effectiveness in preventing chyle leaks during esophagectomy for cancer.

## Key findings

- ICG-Lg visualized the thoracic duct in 95.4% of cases and reduced chyle leak incidence significantly.
- The technique was associated with a higher lymph node harvest and minimal procedural complications.
- Study quality was moderate, and randomized trials are needed to confirm surgical determinants of CL prevention.

## Abstract

Chyle leakage (CL) is a potentially life-threatening complication, severely impacting postoperative recovery after esophageal cancer resections. Indocyanine green-assisted lymphography (ICG-Lg) seems to provide a fluorescent visualization of the thoracic duct (TD), although the optimal approach for CL prevention has not been defined.

This study was designed as a systematic review and included either randomized or observational reports regarding ICG-Lg during esophageal cancer resections. The literature search was conducted on PubMed, Embase, and Scopus databases, and original articles combining ICG-Lg during esophageal cancer resections were selected. The rate of TD visualization was primarily investigated, while secondary outcomes included procedural complications, CL incidence, length of stay, and lymph node harvest (LNH). The review was registered on PROSPERO (CRD42025638309) and was performed according to PRISMA guidelines.

Thirteen non-randomized articles were selected, including 1218 patients undergoing surgery for esophageal cancer. MINORS study quality assessment showed moderate scores (74.5%). The TD was correctly visualized in 95.4% and generally preserved (68.1%) for CL prevention. Procedural complications were negligible (0.1%), and CL occurrence was significantly lower after ICG-Lg (1.4 vs 5.4%, P<0.001). The studies demonstrated a shorter LOS (OR -0.13, 95% CI -0.30 to 0.04, P = 0.273) and a significantly higher LNH (OR 0.40, 95% CI -0.20 to 1.00, P<0.001) after ICG-Lg.

Although intraoperative ICG-Lg provides a safe and effective TD visualization during esophagectomy, minimization of postoperative CL and maintenance of extensive lymph node dissection depends on the surgical strategy. Randomized trials should be specifically designed to identify surgical determinants of CL prevention in esophageal cancer surgery.

https://www.crd.york.ac.uk/prospero/, identifier CRD42025638309.